Ch 16 Nursing management During the Postpartum Period
A) Document the finding, as it is a normal finding at this time.
1. A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take? A) Document the finding, as it is a normal finding at this time. B) Contact the physician, as it indicates early DIC. C) Contact the physician, as it is a first sign of postpartum eclampsia. D) Obtain an order for a CBC, as it suggests postpartum anemia.
B) Offering round-the-clock nursery care for all infants
10. A nurse is reviewing the policies of a facility related to bonding and attachment with newborns. Which practice would the nurse identify as needing to be changed? A) Allowing unlimited visiting hours on maternity units B) Offering round-the-clock nursery care for all infants C) Promoting rooming-in D) Encouraging infant contact immediately after birth
A) Early parent-infant contact following birth
11. When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure? A) Early parent-infant contact following birth B) Expert medical care for the labor and birth C) Good nutrition and prenatal care during pregnancy D) Grandparent involvement in infant care after birth
C) Placing her hand in a basin of cool water
12 A postpartum woman is having difficulty voiding for the first time after giving birth. Which action would be least effective in helping to stimulate voiding? A) Pouring warm water over her perineal area B) Having her hear the sound of water running nearby C) Placing her hand in a basin of cool water D) Standing her in the shower with the warm water on
A) Placing the call light within her reach
13. The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which of the following would be a priority? A) Placing the call light within her reach B) Teaching her how the sitz bath works C) Telling her to use the sitz bath for 30 minutes D) Cleaning the perineum with the peri-bottle
A) History of diabetes D) Hemoglobin level 10 mg/ dL E) Placenta requiring manual extraction
14. A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? (Select all that apply.) A) History of diabetes B) Labor of 12 hours C) Rupture of membranes D) Hemoglobin level 10 mg/ dL E) Palcenta requiring manual extraction
C) Temperature of 101 F
15. A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem? A) Lochia rubra with a fleshy odor B) Respiratory rate of 16 breaths per minute C) Temperature of 101 F D) Pain rating of 2 on a scale from O to 10
B) Light
16. The nurse is assessing a postpartum clients lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which of the following? A) Scant B) Light C) Moderate D) Large
C) Through the anal sphincter muscle
17. When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which area? A) Superficial structures above the muscle B) Through the perineal muscles C) Through the anal sphincter muscle D) Through the anterior rectal wall
B) Mother making eye-to-eye contact with the newborn
18. A nurse is observing a postpartum client interacting with her newborn and notes that the mother is engaging with the newborn in the en-face position. Which behavior would the nurse be observing? A) Mother placing the newborn next to bare breast. B) Mother making eye-to-eye contact with the newborn C) Mother gently stroking the newborns face D) Mother holding the newborn upright at the shoulder
B) Placenta Previa D) Hydramnios E) Labor augmentation
19 After teaching a group of nurses during an in-service program about risk factors associated with postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which risk factors? (Select all that Apply) A) Prolonged labor B) Placenta Previa C) Null parity D) Hydramnios E) Labor augmentation
C) Apply an ice pack to the site.
2. A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure? A) Offer warm blankets. B) Encourage the woman to void. C) Apply an ice pack to the site. D) Offer a warm sitz bath.
C) "I apply glycerin-based gel to my nipples"
20. A postpartum woman who is breast-feeding tells the nurse that she is experiencing nipple pain. After teaching the woman about possible suggestions, the nurse determines that more teaching is needed when the woman makes which statement? A) "I use a mild analgesic about 1 hour before breast-feeding" B) "I apply expressed breast milk to my nipples" C) "I apply glycerin-based gel to my nipples" D) "My baby latches on"
B) Possible experience of fluctuations in sexual interest C) Use of a water based lubricant to ease vaginal discomfort. E) Possibility of increased breast sensitivity during sexual activity
21 A nurse is developing a teaching plan about sexuality and contraception for a postpartum woman who is breast-feeding. Which information would the nurse most likely include? (Select all that apply.) A) Resumption of sexual intercourse about two weeks after delivery B) Possible experience of fluctuations in sexual interest C) Use of a water based lubricant to ease vaginal discomfort D) Use of combined hormknal contraceptives for the first 3 weeks E) Possibility of increased breast sensitivity during sexual activity
B) I should wash my hands before starting to breast-feed.
22. After teaching a postpartum woman about breast-feeding, the nurse determines that the teaching was successful when the woman makes which statement? A) I should notice a decrease in abdominal cramping during breast-feeding. B) I should wash my hands before starting to breast-feed. C) The baby can be awake or sleepy when I start to feed him. D) The babys mouth will open up once I put him to my breast.
B) 2 to 4 ounces
23. A postpartum woman who is bottle feeding her newborn asks the nurse, "about how much should my newborn drink at each feeding?" The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding? A) 1 to 2 ounces B) 2 to 4 ounces C) 4 to 6 ounces D) 6 to 8 ounces
B) Identify common features between themselves and the newborn D) Make direct eye contact with the newborn
24. A nurse is observing a postpartum woman and her partner interact with the their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which behavior? (Select all that apply.) A) Frequently ask for the newborn to be taken from the room B) Identify common features between themselves and the newborn C) Refer to the newborn as having a monkey-face D) Make direct eye contact with the newborn E) Refrain from checking out the newborns features
C) Docusate (Colace)
3. A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following medications to be prescribed? A) Ferrous sulfate (Feosol) B) Methylergonovine (Methergine) C) Docusate (Colace) D) Bromocriptine (Parlodel)
B) demonstrating comfort measures to quiet a crying infant
A nurse is preparing a couple and their newborn for discharge. Which instructions would be most appropriate for the nurse to include in discharge teaching? A) introducing solid foods immediately to increase sleep cycle B) demonstrating comfort measures to quiet a crying infant C) encouraging daily outings to the shopping mall with the newborn D) allowing the infant to cry for at least an hour before picking him or her up
B) He looks like a frog to me.
4. A nurse is observing a new mother interacting with her newborn. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn? A) You have your daddys eyes B) He looks like a frog to me. C) Where did you get all that hair? D) He seems to sleep a lot
B) 1500
A woman gave birth to a healthy-term neonate today at 1330. It is now 1430 and the nurse has completed the client's assessment. At which time would the nurse next assess the client? A) 1445 B) 1500 C) 1530 D) 1830
B) Frequent scant voidings
5. After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? A) Presence of lochia serosa B) Frequent scant voidings C) Fundus firm, below umbilicus D) Milk filling in both breasts
C) Apply ice packs to your breasts to reduce the amount of milk being produced.
6. A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction by the nurse would be most appropriate to aid in relieving her discomfort? A) Express some milk from your breasts every so often to relieve the distention. B) Remove your bra to relieve the pressure on your sensitive nipples and breasts C) Apply ice packs to your breasts to reduce the amount of milk being produced. D) Take several warm showers daily to stimulate the milk let-down reflex.
B) Developing Rh sensitivity
7. The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh-positive newborn based on the understanding that this drug will prevent her from: A) Becoming Rh positive B) Developing Rh sensitivity C) Developing AB antigens in her blood D) Becoming pregnant with an Rh-positive fetus
C) Uterine atony, placenta previa, operative procedures
8. Which factor in a clients history would alert the nurse to an increased risk for postpartum hemorrhage? A) Multiparity, age of mother, operative delivery B) Size of placenta, small baby, operative delivery C) Uterine atony, placenta previa, operative procedures D) Prematurity, infection, length of labor
C) Bonding
9. When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by parents during the first 30 to 60 minutes after birth. The nurse refers to this process by which term? A) Reciprocity B) Engrossment C) Bonding D) Attachment
B) 10 to 25 mL
A nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse interprets this finding as indicating which amount of blood loss? A) 10mL B) 10 to 25 mL C) 25 to 50 mL D) over 50mL
B) :Getting some outside help for housework can lessen feelings of being overwhelmed"
A nurse is conducting a class for pregnant women who are in their third trimester. The nurse is reviewing information about the emotional changes that occur in the postpartum period, including postpartum blues and postpartum depression. After reviewing information about postpartum blues, the group demonstrated understanding when they make which statement about this condition" A) "Postpartum blues is a long-term emotional disturbance" B) "Getting some outside help for housework can lessen feelings of being overwhelmed" C) "The motor loses contact with reality" D) "Extended psychotherapy is needed for treatment"
B) Commitment
After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify which concept as reflecting the enduring nature of their relationship, one that involves placing the infant at the center of their lives and finding their own way to assume the parental identity? A) reciprocity B) commitment C) bonding D) attachment
C) observe the parents performing the procedures
Which method would be most effective in evaluating the parents' understanding about their newborn's care? A) demonstrate all infant care procedures B) allow the parents to state the steps of the care C) observe the parents performing the procedures D) routinely assess the newborn for cleanliness
